Your embryo may arrive with a barcode attached

December 15, 2010Carole 2 Comments »

When our son was born and we were getting ready to go home, our nurse cheerfully cut off his ankle identity band and said, “I’ve removed his tags. He’s yours now. No returns. No refunds”. That was sort of weird but consider this, your  IVF baby may soon be issued her own bar code before the egg is even fertilized.

Researchers as the Universitat Autonoma de Barcelona in Spain are testing barcodes embedded in embryos as a way to prevent IVF lab mix-ups. This link takes you to a picture of the bar codes on the mouse embryos. Silicon bar codes  are injected inside the perivitelline space between the embryo and the shell or zona pellucida. The bar codes are injected into the perivitelline space of the egg prior to fertilization and the bar code remains there until hatching, when it is presumably left behind when the zona pellucida is shed.  At various critical stages in the lab, a scanner can be used to scan the eggs and match eggs to sperm, scan the embryos and match embryos to intended recipient (intended mom or gestational surrogate) with the correct matching arm band. Since mouse studies were promising, the Spanish scientists are planning human clinical trials next. The mouse studies were published recently in the journal Human Reproduction and the free abstract is available on-line. The complete reference: A Novel Embryo Identification System by Direct Tagging Using Silicon-Based Barcodes. Novo, S., Barrios, L., Santaló, J., Gómez-Martínez, R., Duch, M., Esteve, J., Plaza, J.A., Nogués, C., Ibáñez, E. Human Reproduction. doi:10.1093/humrep/deq309.

IVF mix-ups in the lab are truly horrible for everyone involved so why shouldn’t we jump at a chance to eliminate the risk completely? Well, even assuming that there are no health risks to the embryos from being repeatedly subjected to scanning with some kind of illumination system (ranging from LED lights to lasers), I am doubtful that this high tech solution will end IVF mix-ups.

Barcodes are all the rage in health care right now because patient safety and achieving right patient, right drug, right dose, right route and right time are a primary focus of the Joint Commission which sets standards for hospital safety. The idea is that when a patient is admitted to the hospital, they  are issued a unique bar code on a wrist band that they must wear all the time while in the hospital. When medications are ordered for the patient, the medications get a matching bar code and voila, the nurse can scan the patient and the med to ensure the right match before the medication is given.

So what can possibly go wrong? Plenty, according to a study by Ross Koppel, PhD, a sociologist at the University of Pennsylvania and a researcher  at the Center for Clinical Epidemiology and Biostatistics at UPenn’s School of Medicine. The journal Today’s Hopitalist published a fascinating article on Koppel’s study written by Ingrid Palmer, ” Study finds big gaps in barcode safety: Workarounds are derailing critical features“. One in five hospitals use this barcode technology and more are expected to adopt this technology as time goes on. Dr. Koppel studied the implementation of this system in five hospitals and found that nurses overrode the bar code system for 4.2% of patients charted and for 10.3% of medications administered.

Why did nurses do this? Well, it turns out that the bar code scanner wasn’t very compatible with the nurses’ work flow. If a patient was asleep, nurses were reluctant to pull on the patient’s arm to find the bar code and scan it so they might omit this step. Sometimes, the computer (and the audible alert) stayed in the hallway and only the hand held scanner entered the room so nurses couldn’t hear the warning signal of a mismatch.

Sometimes, because nurses felt rushed to get everything done, they pre-scanned several patients meds and carried them all around on the same tray as they went room to room, leaving open the real possibility of giving the right patient the wrong medication. We have a new self-serve scanning system at our local library to check out books. Turns out that I don’t actually have to wave the book directly under the scanner but only have to get the book within a foot of the scanner for the scanner to “see” my book. If multiple patients meds are on the same tray, who knows which one the scanner is picking up and which one the nurse is physically picking up to administer.

Some nurses, in an effort to be more efficient, started wearing several patients wrist bands around their own arm rather than bringing their sick and elderly patients to where the medications were stored to scan the patient and the medication. Nurses were coming up with work arounds because the technology caused problems for them as they tried to take care of patients. Unfortunately, their solutions were defeating the safety  goal of identity-scanning.

Technology may actually lull us into a dangerous state of mind. When we rely on technology to do our thinking for us, we are more vulnerable to making errors because we don’t expect errors to happen. If we rely on the scanner, we stop relying on our own mindfulness to avoid making mistakes. In the study, nurses sometimes omitted a double check with a colleague perhaps because having the scanner was all the reassurance they needed. If you can scan a bar code, do you bother reading the label on the vial, do you bother thinking about whether this drug/dose/timing makes any sense based on your medical knowledge? Frankly, if we don’t care if nurses are on the job thinking, we can probably replace them with grocery cashiers if all they need is scanning skills! That would be tragic.

In my experience, lab errors happen when the operator’s mind is somewhere else, when they are disengaged from what they are doing, thinking about the next case, personal problems or what’s for dinner. Scanning gives something else the responsibility of getting it right, freeing you up to think about other things- which is a very dangerous practice.

Every year, I’d  go to the trade shows and see what new IVF identity scanning system was coming down the pike. Every year, I would ask, so what if my tech enters the wrong information at the first step? Every year they would have to admit that their system couldn’t prevent human error at the beginning. A human would have to be “on the ball” at the beginning of the identify matching system or the whole thing didn’t work.

If I have embryos from two different patients within reaching distance of each other, I can scan every dish and still not be assured that when I reach for a dish, I don’t grab the wrong one. The simplest rules provide the most safety. Only work on one case at a time. Only have one patient’s dishes out of the incubator at a time. Read the dish, say the name out loud if you have to, just to force your mind back to the here and now, this patient, this case, this procedure. Check yourself against another human being. Be in the moment when you are working with embryos, constantly analyze what you are doing and whose embryos you are working on to prevent rote robotic “doing” that causes mistakes.

When building safer health care systems, we need to put the human factor first and give people the mental resources to do their job as safely as possible. I asked my technicians to read the ART of Mindfullness, a yoga based concept of being in the moment. The idea translated to the embryologist’s work life is that you need to be aware of your thinking processes, at least enough to realize when you are day dreaming. I also empowered them to reach out for “mental health breaks” when they felt they were getting distracted or mentally exhausted with a particular task.  Technology without mindfullness tends to push people out of the way until mistakes happen and someone needs to be blamed.

© 2010, Carole. All rights reserved.

2 Responses to this entry

  • gingerandlime Says:

    This is fascinating. What you’re talking about sounds like a much more serious version of what I usually call “GPS Makes You Stupid.” I have been on a road trip in which 4 otherwise intelligent adults all agreed to pass up what was obviously our exit because the display on the GPS was running slow and showed us still going straight. We put our faith in it and turned our brains off. It’s scary to think about this going on with something that’s so much more important.

  • Carole Says:

    Thanks for your story. it’s a great illustration of the problem. I was sewing something the other day on the sewing machine and realized my mind had wondered off as my seam started to curve away from straight. Fortunately, I don’t make a living sewing! But you are right, the stakes are way higher in other circumstances and we need to think really carefully about safety systems that keep people in the moment and actively thinking instead of lulling them into a false sense of security.

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